2016 ACP Colorado Chapter Meeting- February 4, 2016 thru February 6, 2016 Broadmoor Hotel, Colorado Springs, Colorado

Resident Abstracts

Presented: February 5, 2016

2016 ACP Colorado Chapter Meeting- February 4, 2016 thru February 6, 2016 Broadmoor Hotel, Colorado Springs, Colorado

Name: Nicole Barberis, MD

Presentation Type: Oral

Residency Program: Saint Joseph Hospital Additional Authors: Jeff Owsley, DO Abstract Title: Intermittent Massive Hemoptysis Abstract Information: Case Description This is a 60yo female with history of intermittent hemoptysis, AVR, hemi-aortic arch replacement on anticoagulation that presented for large volume hemoptysis. She was initially treated with empiric pulse dose steroids and plasmapheresis X 5d. She had negative vasculitis workup several times and differential diagnosis at that time was diffuse alveolar hemorrhage (DAH) or pauci immune pulmonary capillaritis. Her initial bronchoscopy was concerning for DAH though localized to right lower lobe as the blood did not clear with serial lavage. She underwent bronchial artery angiography, which did not reveal a structural source of her bleeding. There was concern that there could be a cardiac etiology to her bleeding such as severe MR leading to hemolysis. She had an ECHO, which showed good function of the valves and right heart cath showed normal pressures. On hospital day 9 she had another episode of large volume hemoptysis causing shock and required blood transfusion. She was emergently intubated at that time and another bronchoscopy was done which appeared to localize the bleeding to the superior segment of the left lower lobe. CT angiography supported this location as a source. She was started on an empiric course of plasmapheresis and rituximab to treat presumed vasculitis. On a follow up bronch there were tracheal lesions, which appeared to be benign granulation tissue. Thoracic surgery was consulted for possible segmentectomy, however, they suggested repeat attempt at IR embolization, which was not possible at our hospital so the patient was transferred to the University of Colorado Hospital. She had another CT angio there that showed a concerning lesion at the area of the aortic arch repair extending from the aortic arch to close proximity to the left lateral tracheal wall. A repeat right heart cath showed a dilated aortic arch with an ulceration at the aortic root repair suture line that may be concerning for possible occluded fistula vs pseudoaneurysm. A pre op bronchoscopy was done which showed a pulsating erosion noted 3cm above the carina on the anterior portion of the trachea. She had surgical repair of the defect. Postoperative diagnosis was direct communication between pseudoaneurysm of distal aortic anastomosis to trachea with ulcer corresponding to this communication within the tracheal wall. Case Discussion This case is exceptional because this patient had four discrete episodes of massive hemoptysis secondary to a tracheal aortic fistula. Tracheal aortic fistulas have been reported rarely in the literature in the adult population and the majority of these few cases are of tracheal innominate artery fistula after tracheostomy. The intermittent nature of the bleeding is unique given the connection was with the aorta and you would expect constant flow and life threatening hemoptysis without stopping. There is commonly a sentinel bleed in trachea-aortic fistula but rare to have more than one as they will often be lethal. This case illustrates the importance of recognizing this defect in adult patients and surgical correction of a

fistula in a symptomatic patient. Our patient responded well to appropriate surgical correction of the defect and has had no complications or further hemoptysis even after resuming anti coagulation. The internal medicine provider can take away a few important points from this case. First there is a broad differential diagnosis for pulmonary hemorrhage that should be worked through in a step wise manner with a pulmonary specialist. It is important to find the etiology of the bleeding, as it could be life threatening in some cases. It is important to always search for the underlying cause and understand the limitations of your knowledge and the abilities of the facility and transfer to a higher level of care if needed.

2016 ACP Colorado Chapter Meeting- February 4, 2016 thru February 6, 2016 Broadmoor Hotel, Colorado Springs, Colorado

Name: Kathleen Batley, MD, M.Sc.

Presentation Type: Oral

Residency Program: University of Colorado Health Science Center Additional Authors: Allison Nitsch, MD Abstract Title: A Mis-LEADing Presentation of Angioedema Abstract Information: A 76 year-old male veteran with end stage renal disease (ESRD) with a right upper extremity AV fistula, diabetes, and complete heart block status post pacemaker placement presented with complaints of facial swelling and new onset dyspnea after completion of his scheduled hemodialysis (HD) session. He reported increasing facial and tongue swelling after each HD session over the past month. Prior to this presentation, his symptoms had not been accompanied by dyspnea. He had no new medications and was not taking an ACE inhibitor or ARB. Vital signs were within normal limits. He had right neck and face swelling without stridor or stigmata of respiratory distress. Skin exam did not reveal rash or hives. A portable chest x-ray demonstrated mild pulmonary edema without any. A bedside fiberoptic laryngoscopy revealed mild epiglottic and supraglottic edema. Our patient was admitted to the intensive care unit (ICU) for airway monitoring, given epinephrine, and started on solumederol, famotidine and diphenhydramine and for suspected angioedema. C4, C1 esterase inhibitor (both qualitative and functional) and C1q level were all within normal limits. Patient symptomatically improved with tapered course of corticosteroids. The day after discharge he again developed facial edema and was readmitted. Computerized tomography (CT) scan of neck revealed chronic superior vena cava narrowing surrounding the pacemaker leads with extensive collaterization. On further questioning of patient, symptoms began after being placed in recumbent position during HD. Vascular surgery was consulted and recommended stenting of the stenotic area. He underwent balloon angioplasty followed by placement of a 14mm x 60mm stent from the subclavian vein to the superior vena cava. This resulted in complete resolution of presenting complaints. Learning objectives 1. Identify differential diagnosis for facial and laryngeal swelling. 2. Recognize SVC syndrome is a rare but possible side effect of pacemaker placement. Facial and laryngeal swelling is commonly encountered by the hospitalist. The differential diagnosis of laryngeal and facial edema includes angioedema (hereditary, acquired and medication induced), allergic reaction, trauma, mass effect and superior vena cava syndrome. Superior vena cava syndrome is most often associated with a malignancy such as bronchial carcinoma or lymphoma. It is rarely a late complication of pacemaker placement with incidence thought to be 1/3100. The etiology is thought to be induced by endothelial disruption from repeated mechanical trauma by the leads against the vessel wall. In our patient was likely to have this exacerbated during his regular HD sessions as the area was under high. Diagnosis can be made by CT of the chest with the gold standard being contrast venography. Treatment includes percutaneous stenting as in our patient but thrombolysis with a short course of anticoagulation has also been used with success.

2016 ACP Colorado Chapter Meeting- February 4, 2016 thru February 6, 2016 Broadmoor Hotel, Colorado Springs, Colorado

Name: Miriam Freundt, MD

Presentation Type: Oral

Residency Program: Saint Joseph Hospital Additional Authors: Svetomir Loukanov, MD, PhD, Falk-Udo, MD, PhD Abstract Title:

Undiagnosed Patent Ductus Arteriosus Complicating Closure of a Large Ventricular

Septal Defect in a 25-year old immigrant with still reversivle pulmonary arterial hypertension

Abstract Information: Background: Ventricular septal defect (VSD) and persisting ductus arteriosus (PDA) create a functional left-to-right shunt and are usually diagnosed early in infancy. If left untreated they can lead to pulmonary artery hypertension (PAH), cyanotic disease and Eisenmenger’s syndrome. In cases of significant VSD shunt, a PDA can have low flow and be missed on echo. A PDA that was unrecognized preoperatively complicated this VSD repair.

Case: A 25-year old immigrant from Eastern Europe presented with progressive dyspnea on exertion and fatigue. He reported taking digoxin for an unknown heart condition. His exam was unremarkable with the exception of a 4/6 pansystolic murmur. Hemoglobin was 16.3 g/dl with unremarkable CBC and CMP. EKG showed normal sinus rhythm and bifascicular block. CXR revealed an enlarged heart with prominent pulmonary vasculature. Echo showed preserved cardiac function but a large membranous VSD (2 x 3 cm). A SwanGanz-Catheter measured PAP of 95/40 mmHg, mean PAP of 56 mmHg, PVR of 205 dyn.s/cm5, SVR of 1465 dyn.s/cm5, CI of 2.5 L/min/m2, and Qp/Qs of 4.5.

After bicaval cannulation, application of cardioplegia and crossclamping of the aorta severe volume overload of the heart occurred despite total cardiopulmonary bypass (CPB). A right atriotomy was performed for a transatrial approach but severe hemorrhage occurred. This situation is characteristic for a PDA, as it allows blood to circulate back from the aorta into the pulmonary artery, left atrium, left ventricle, through the VSD into right ventricle and right atrium while on total CPB. Depending on the PDA size this volume can reach significance and result in inability to unload the heart. After extremely difficult preparation the PDA was successfully closed with two ligature sutures. Bypass was continued without difficulty. The VSD was closed with a patch without complications. Immediately postoperatively nitric oxide was overlapped with sildenafil and PAP came down to 42/25 mmHg. Further recovery was uneventful.

Conclusion: Patients with congenital heart disease should be evaluated for PDA by preoperative echocardiogram. If unrecognized preoperatively, it can significantly complicate surgery due to severe hemorrhage while on total cardiopulmonary bypass.

2016 ACP Colorado Chapter Meeting- February 4, 2016 thru February 6, 2016 Broadmoor Hotel, Colorado Springs, Colorado

Name: Stephanie Murphy, DO

Presentation Type: Oral

Residency Program: Parkview Medical Center Additional Authors: Abstract Title: A Devastating complication of epidural injection for chronic back pain Abstract Information: Introduction: This is a case of a patient who presented with complaints of back and lower extremity pain with associated weakness and urinary incontinence following an epidural injection for chronic back earlier that day. Case Description: The patient is a 69 year old female with a past medical history of coronary artery disease, breast cancer and osteoarthritis who presented to the hospital complaining of back and leg pain with associated lower extremity numbness. She had received an epidural injection earlier the same day for chronic back pain. Of note, the patient has had multiple previous successful therapeutic epidural injections. She was able to ambulate to her car post procedure however noted she had difficulty ambulating out of her car once she arrived home and approximately 20 minutes later reported bilateral lower extremity pain and weakness with associated loss of urinary function. A lumbar MRI was performed as a part of her initial evaluation in the ED. Imaging was initially interpreted by offsite radiology that evening as: severe central stenosis with prominent posterior epidural fat “incidental / non-acute findings.” The ED physician reported these findings to the on-call neurosurgeon who felt it would be appropriate to evaluate the patient the following morning. The initial lower extremity exam by the ED physician does not make any notation of strength deficits however; the admitting physicians noted a left lower extremity strength of 2 out of 5 and a right lower extremity strength of 3 out of 5. The following day the on-site radiologist interpreted the lumbar spine MRI as having a posterior epidural fluid collection that could possible represent an epidural hematoma, 9 mm x 5cm in size from L1-L4 with compression to the intrathecal nerve roots. The patient’s medical team was alerted to the discrepancy. The patient was then taken to surgery for decompressive laminectomy and foraminotomy. Following surgery, she has persistent near total loss of strength in both of her lower extremities and loss of bowel and bladder control. Discussion: Unfortunately this case was complicated both by a delay in diagnosis as well as a known procedural risk. Although the patient has a previous history of successful therapeutic epidural injections for chronic back pain management, the procedure is non-FDA approved with recent studies indicating limited clinical benefits. Given the devastating effects of the complications associated with this procedure and limited benefit in the treatment of chronic back pain, this case calls into question the risk versus benefits for routine use of therapeutic epidural injections. References: Epstein, N. (n.d.). The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature. Surgical Neurology International Surg Neurol Int, 74-74. Racoosin, J., Seymour, S., Cascio, L., & Gill, R. (2015). Serious Neurologic Events after Epidural Glucocorticoid Injection — The FDA's Risk Assessment. New England Journal of Medicine N Engl J Med, 1-3.

2016 ACP Colorado Chapter Meeting- February 4, 2016 thru February 6, 2016 Broadmoor Hotel, Colorado Springs, Colorado

Name: Melissa Reidy, MD

Presentation Type: Oral

Residency Program: University of Colorado Health Sciences Center Additional Authors: William Kim, MD, Nhat-Tuan Tran Abstract Title: Hungry Hearts Abstract Information: Introduction: Celiac disease (CD) is a chronic malabsorptive syndrome of genetically susceptible individuals who ingest gluten, which is found in grains such as wheat, rye, and barley. Previously described as a disease of European ancestry, it is believed to affect up to 1% of the general population [1]. Although classically associated with iron deficiency anemia, vitamin deficiencies, and gastrointestinal complaints, the majority of patients with celiac disease exhibit minor or non-gastrointestinal manifestation; however, only a minute number of cases have described the association between celiac disease and cardiomyopathy [2]. We describe a young patient with rapid onset dilated cardiomyopathy in the setting of iron deficiency anemia who was found to have underlying celiac disease.

Case description: An 18 year old male with a long standing history of severe iron deficiency anemia who presented with fevers, shortness of breath, hemoptysis, and cough. He had originally been seen at an outside hospital and treated for community acquired pneumonia and discharged. Despite treatment, his symptoms continued to worsen, and the patient was admitted 3 days later. Review of systems was significant for palpitations with activity and occasional dizziness. On physical exam, the patient had tachycardia, pallor, cachectic appearance, and an abdominal exam with mild tenderness to palpation on left upper and lower quadrants without guarding. Initial work up showed laboratory findings consistent with iron deficiency anemia and elevated ESR and CRP. Notably, an EKG showed findings of a new left bundle branch block with a prolonged QT interval and non-specific T wave changes while troponins were negative. CT chest imaging revealed pulmonary edema, dilated left ventricle, and cardiomegaly. An echocardiogram showed an ejection fraction of 20-30%. While workups for viral, infiltrative, and rheumatologic etiologies of cardiomyopathy were largely negative, Gliadin IgA and IgG antibody screens were positive, suggestive of celiac sprue. The patient was discharged with instructions to avoid gluten containing foods and was scheduled for GI and Cardiology follow up. Unfortunately, this writer encountered the patient on the inpatient Cardiology service one year after discharge where he was found to have decompensated CHF with a new EF 10% after failing to follow-up with either GI or Cardiology. He also reported dietary non adherence. He is now on the heart failure team to consider work-up for advanced therapies. Discussion: Celiac-induced cardiomyopathy has been infrequently discussed in studies. Many mechanisms for development of DCM due to CD have been proposed: carnitine deficiency due to chronic malabsorption, increased absorption of intestinal infectious agents causing myocardial damage, and auto-immune destruction. Only association between CD and DCM has been indicated in approximately 1-5% of patients [3,4]. A prevalence study in Iran demonstrated a linear relationship of positive anti transglutaminase and age

suggesting that length of exposure may predispose patients to development of antibodies [5]. Based on these articles and cardiology consultation, this Celiac-induced cardiomyopathy was felt to be the most likely diagnosis. Our case illustrates the importance of determining the underlying cause of DCM as the damage may reversible depending on the diagnosis. The paucity of the data on Celiac-induced cardiomyopathy underscores the difficulty practicing evidence-based medicine (EBM) in a rare disease population. A RCT is unlikely in this or similarly rare populations. This patient required treatment based on case reports alone. This patient’s case demonstrates the imprecise world of medicine that today’s physician still practices in despite the EBM culture.

References: [1] Maki M, Mustalahti K, Kokkonen J, et al. Prevalence of celiac disease among children in Finland. N Engl J Med. 2003;348:2517-2524. [2] Lodha, Ankur, et al. "Celiac disease associated with dilated cardiomyopathy." Southern medical journal 102.10 (2009): 1052-1054.

[3] Barrio, Juan, et al. “Heart transplantation in rapidly progressive end-stage heart failure associated with celiac disease.” BMJ Case Reports. 2011; doi:10.1136/bcr.12.2010.3624.

[4] Menezes, Thaysa, et al. “Celiac disease prevalence in children and adolescents with myocarditis and dilated cardiomiopathy.”J. Pediatr. 2012. vol.88 no.5.

[5] Zahmatkesha, Mozhgan, et al. “Prevalence of Celiac Disease in Children with Idiopathic Dilated Cardiomyopathy.” Iran Journal of Pediatrics. 2014. Vol 24

2016 ACP Colorado Chapter Meeting- February 4, 2016 thru February 6, 2016 Broadmoor Hotel, Colorado Springs, Colorado

Name: Jordan Harrison, MD, MPH

Presentation Type: Poster

Residency Program: University of Colorado Health Sciences Center Additional Authors: Skotti Church, MD, Anne Newman, MD, Ronica Rooks, PhD Abstract Title: Social isolation and Frailty in the Health, Aging and Body Composition Study (HABC). Abstract Information: Background: Social isolation is a risk factor for many different diseases in geriatric populations including increased hospitalization rates, heart disease, cancer, and mortality. Frailty is a complex syndrome marked by loss of function, strength and physiological reserve in elderly individuals. We evaluated the potential relationship between frailty and social isolation in African Americans (AA) and Caucasians. Methods: Cross-sectional study using the HABC study for all individuals enrolled during the first year of the study (1997-1998). The Lubben Social Network Scale (LSNS) was used to measure social isolation and fatigue and the 400meter walk test were used to measure frailty. First, the LSNS was categorized into 4 levels based on the commonly used clinical cutoffs. Second, a 2 level categorical variable based on the LSNS cutoff of less than 16, which is considered the most isolated group that we used for bivariate and multivariate analysis. The 400 meter walk test was analyzed for completion as an outcome and as a categorical variable with four levels also based on clinical cutoffs. Multinomial and standard logistic regression to calculate the odds of fatigue or impaired 400 meter walk test results were stratified by race. Results: In bivariate analysis, 400 meter walk speed was significantly slower in socially isolated individuals (321 seconds vs. 317 seconds, p.05) and the 400 meter walk score (OR 1.12, 95% CI .931-1.34, p>.05.) In multivariate analysis of Caucasians using the categorical LSNS as the exposure, the outcomes are as follows fatigue (OR 0.88, 95% CI.58-1.128, p>.05), ability to complete the 400 meter walk test (OR 1.06, 95% CI.83-1.35, p>.05), and the 400 meter walk test (OR 1.06, 95% CI .924-1.297, p>.05.) Using the most isolated group as the exposure, the results of the multivariate analysis for AA are as follows: fatigue (OR 1.71, 95% CI 1.13-2.59, p.05), the 400 meter walk test (OR 1.03, 95% CI.76-1.33, p.05), the ability to complete the 400 meter walk (OR 1.16, 95% CI .88-1.5, p>.05), the 400 meter walk test (OR 0.96, 95% CI.77-1.21.)

Conclusion: These findings suggest that social isolation may be a risk factor for frailty among wellfunctioning elderly, especially in African Americans. More longitudinal investigation and awareness of social isolation is needed in the medicine and public health.

2016 ACP Colorado Chapter Meeting- February 4, 2016 thru February 6, 2016 Broadmoor Hotel, Colorado Springs, Colorado

Name: Claudia Ihm, MD

Presentation Type: Poster

Residency Program: Saint Joseph Hospital Additional Authors: Bryan Knepper, MPH, MSc, Heather Young, MD Abstract Title: Clinical Characteristics of patients diagnosed with communityassociated Clostridium Abstract Information: Objectives: Community-associated Clostridium difficile infection (CA-CDI) is increasing, and many patients with CA-CDI lack traditional risk factors. In fact, a large number of CA-CDI patients have no previous antibiotic exposure, and they tend to be younger and healthier compared to patients with hospital-associated CDI. However, risk factors for CA-CDI are not well understood. We conducted a retrospective study to determine the clinical characteristics of CA-CDI. Methods: Patients with potential CA-CDI were identified from a database maintained for infection control surveillance at an urban hospital in Denver, Colorado, between 10/1/2012 and 9/30/2014. Patients were included if they were tested positive for C. difficile. The National Healthcare Safety Network definition was used to define CA-CDI. A chart review was conducted to determine previous antibiotic exposure. Health care contact in the 6 months prior to CDI, including hospital stay, clinic visits, acute care or ED visits, outpatient surgery